Abstract: BACKGROUND: Limited data are available on clinical outcome of patients with previously failed or not attempted chronic total occlusion (CTO) recanalization by percutaneous coronary intervention (PCI). The aim of the study is to determine prevalence and predictors of cardiac death in patients with CTO not revascularized by PCI. METHODS: Double-center study analyzing data of 1.345 consecutive patients with at least one CTO between 1998 and 2008. Of these, 847 patients were successfully revascularized (Revascularized group) and 498 patients were not revascularized (Not revascularized group) either due to failure of CTO-PCI (n=337) or because no attempt was made (n=161). RESULTS: At 4-year clinical follow-up, Not revascularized patients had a significantly higher rate of cardiac mortality (8.5% vs. 2.5%, p<0.0001) and sudden cardiac death (2.7% vs. 0.5%, p=0.001) compared to those Revascularized. The separate adjusted Cox-model analysis made for Not revascularized patients showed the most significant independent predictors of cardiac death were: chronic renal failure [HR (CI), 6.0 (2.66-13.80)], low-LVEF [5.7 (2.84-11.58)], insulin-dependent diabetes mellitus (IDDM) 4.6 [(1.96-10.97)]. In the Revascularized group, the presence of 3-vessel disease was the only significant independent predictor of cardiac death [4.4 (1.40-13.70)]. CONCLUSIONS: CTO patients Not revascularized had a significant higher rate of cardiac mortality and sudden cardiac death compared to those Revascularized. Within Not revascularized patients, the presence of low-LVEF, or CRF or IDDM was associated with an incidence of cardiac death at least 4 times higher than those without the same risk factors.
Abstract: Encouraging results at long-term follow-up have been reported from non-randomized registries and randomized trials following percutaneous coronary intervention with drug-eluting stent implantation for unprotected left main stenosis. However, information on very long-term (>5-year) outcomes is limited. The aim of this study was to assess the very long-term outcomes (6-years) following drug-eluting stent implantation for left main disease.
Abstract: Little is known about gender differences among patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO).
Abstract: There are limited data on the mid-term safety following the use of the guided-subintimal tracking and re-entry (guided-STAR) technique for the treatment of chronic total occlusions (CTO) and concerns have arisen about a potential increased risk of stent thrombosis (ST).
Abstract: Aims: Unlike most diagnostic procedures, the MitraClip® therapy requires precise positioning of transseptal access to ensure a successful procedure. Radiofrequency-based transseptal puncture has been developed to reduce complications and improve precision of septal access. We report our experience utilising surgical diathermy-based transseptal puncture for MitraClip implantation. Methods and results: Between October 2008 and April 2010, 72 patients underwent MitraClip therapy. Diathermy-assisted transseptal access was performed in 66 patients, under echocardiographic guidance, by manual contact of the diathermy blade with the Brockenbrough needle at the groin. Rate of successful puncture, time from femoral vein puncture to transseptal access and rate of complications were analysed. Diathermy-assisted puncture was successful in all cases. Time from femoral vein access to transseptal puncture was 16±19 min. There was one suboptimal septal puncture position (too low), and there was one coronary artery air embolism. There were no cases of intraprocedural pericardial effusion or arrhythmias. Conclusions: Surgical diathermy-based transseptal puncture may be a safe and effective alternative to either conventional or RF-based septal crossing. It improves precision of the septal access and may reduce the risk of bleeding complications. This technique is now routinely used at our institution for all MitraClip procedures.
Abstract: This study aims to report a "real-world" experience of in hospital complications and clinical outcome of a large cohort of consecutive patients who underwent percutaneous coronary intervention (PCI) with intra-aortic balloon pump counterpulsation (IABP) support, from a tertiary care center over a 12-year period.
Abstract: The concomitant use of femoral and popliteal accesses has been recommended for challenging superficial femoral artery (SFA) occlusions, but no comprehensive comparison of this approach to a strategy of femoral access only is available. We thus aimed to appraise the risk-benefit balance of retrograde popliteal access as bail-out strategy for SFA occlusions.
Abstract: Reoperation for bioprosthetic heart valve failure is associated with significant morbidity and mortality, particularly in high-risk patients. Transcatheter valve-in-valve (VIV) implantation may offer a less invasive alternative. The aim of this study was to report our initial experience with transcatheter VIV implantation to treat degenerated tissue valves.
Abstract: Neutrophils are involved in thrombus formation. We investigated whether specific features of neutrophil activation characterize patients with acute coronary syndromes (ACS) compared to stable angina and to systemic inflammatory diseases.
Abstract: To assess clinical performance of the second-generation Endeavor Resolute(®) drug-eluting stents (DES) in an unrestricted high-risk cohort of patients.
Abstract: The aim of the study was to investigate the changes in quality of life (QoL) following transcatheter aortic valve implantation (TAVI) up to two years' follow-up.
Abstract: Few data are available regarding the optimal revascularization strategy for unprotected distal left main coronary artery (UDLM) in-stent restenosis (ISR).
Abstract: There is a frequent association between aortic valve stenosis and gastrointestinal bleeding, also known as Heyde's syndrome. In these patients, the aortic valve replacement should be recommended as "gold standard." In high-surgical-risk patients, the Transcatheter Aortic Valve Implantation (TAVI) is an alternative option. However, the risk of bleeding recurrence, related to double antiplatelet therapy started after TAVI, cannot be excluded especially in the first months. We present a case of a patient with a severe aortic valve stenosis and a history of previously documented angiodysplasia and recurrence of gastrointestinal bleeding initially treated only with balloon aortic valvuloplasty that excluded recurrence of bleeding during the subsequent six months of followup. Therefore, a definite transfemoral Edwards XT valve implantation was planned to be performed in case of recurrence of aortic stenosis.
Abstract: Unlike most diagnostic procedures, the MitraClip® therapy requires precise positioning of transseptal access to ensure a successful procedure. Radiofrequency-based transseptal puncture has been developed to reduce complications and improve precision of septal access. We report our experience utilising surgical diathermy-based transseptal puncture for MitraClip implantation.
Abstract: Trans-catheter aortic valve implantation (TAVI) is an alternative for patients not eligible for surgical aortic valve replacement. When peripheral access is not amenable by the transfemoral route (TF-TAVI), the most-used approaches are the trans-apical (TAp-TAVI) and the trans-axillary (TAx-TAVI). The aim of this study is to report the outcomes in a single-center series of consecutive patients treated by TAVI using the different approaches.
Abstract: Rapid right ventricular pacing (RRVP) at rates above 200 beats/minute is used to suppress cardiac output during balloon aortic valvuloplasty (BAV) in transcatheter aortic valve replacement (TAVI) patients. A risk of inducing myocardial ischemia with RRVP remains, especially in patients with left ventricular dysfunction. Alternatively, a transient cardiac arrest can be achieved with administration of adenosine.
Abstract: BACKGROUND: Dual antiplatelet therapy (DAT, i.e. aspirin+thienopyridine) has been shown to reduce the risk of stent thrombosis (ST) and myocardial infarction (MI) after coronary stent implantation. Data regarding alternative antiplatelet therapy in patients with allergy or intolerance to aspirin are lacking. METHODS: This study is a retrospective analysis of consecutive patients with adverse reactions to aspirin who received an alternative combination of DAT (indobufen, trapidil, or triflusal in association with a thienopyridine) after elective implantation of either drug-eluting (DES) or bare-metal stents (BMS). Endpoints analyzed were cardiac death, MI, ST and bleeding. RESULTS: A total of 127 patients undergoing stenting of 267 lesions (DES 84%, BMS 16%), were identified between June'99 and November'08. Reasons for not taking aspirin included gastrointestinal intolerance (53.5%), allergy (39.4%), non-gastrointestinal bleeding (5.5%) and others (1.6%). Aspirin was substituted with indobufen (64.6%), trapidil (26.8%), triflusal (6.3%), or a combination of indobufen+trapidil (2.4%). Median duration of DAT was 369days [IQR 273-1053] after DES and 46.5days [IQR 30-699] after BMS implantation. Only 3.1% of patients prematurely discontinued DAT. During a median follow-up of 1161days [IQR 781-1538], rates of cardiac death and MI were 3.1% and minor bleeding occurred in 1.5%. There was 1 very late definite ST occurring 2days after DAT discontinuation and no probable ST. CONCLUSIONS: In this cohort of patients with aspirin intolerance undergoing coronary stent implantation, the combination of a thienopyridine with indobufen, trapidil, or triflusal was associated with a low rate of cardiac death, ST and MI.
Abstract: Cardiac stem cell therapy is a field of scientific research with the goal to translate into clinical benefit the initial findings obtained in basic research laboratories. We have moved into clinical trials in different disease categories: acute myocardial infarction, chronic stable angina refractory to conventional therapy and heart failure. So far we have faced with contradictory results. Some previous studies suggested that bone marrow cell injection may improve myocardial perfusion and left ventricular function in patients with chronic myocardial ischemia.
Abstract: The aim of this study was to analyze the short-term outcomes after transcatheter aortic valve implantation with the Edwards Sapien THV (ESV), compared with the Sapien XT THV (SXT) (Edwards Lifesciences, Irvine, California).
Abstract: Iatrogenic occlusive coronary dissection (IOCD) is a rare but high-risk complication of percutaneous coronary intervention (PCI) with limited data on options for management. The aim of this study was to describe a novel approach to the treatment of IOCD in order to gain access to the true coronary lumen. This technique may be feasible in cases in which conventional methods of PCI have failed.
Abstract: This study sought to evaluate the long-term angiographic and clinical outcomes after the treatment of drug-eluting stent in-stent restenosis (DES-ISR) based on the angiographic pattern of restenosis.
Abstract: Severe mitral regurgitation (MR) confers a poor prognosis, in particular for patients with heart failure. Based on the results of the Euro Heart Survey, a large proportion of patients with mitral regurgitation is not referred to surgery and many other patients are rejected for cardiac surgery due to the high surgical risk or co-pathologies. Improving ventricular function with ACE inhibitors, beta-blockers and CRT may reduce mitral regurgitation, but for most patients a mechanical intervention is ultimately preferable. Mitral valve surgery is invasive and requires a long recovery period; therefore, less invasive and effective approaches are highly desirable, particularly in high risk patients. Therefore, new techniques have been recently developed to treat MR with percutaneous approach. The MitraClip device (Abbott Vascular, Menlo Park, CA) is used to treat both functional and degenerative mitral valve regurgitation. Its safety and efficacy has been initially tested in the Endovascular Valve Edge-to-Edge REpair Study (EVEREST), while MitraClip has been compared to surgery in the EVEREST II randomized trial. Besides EVEREST trials, safety and efficacy of the device as well as its health economic value is under evaluation in ongoing registries. Although the field of catheter based management of MR is at an early stage, initial clinical results have demonstrated that catheter based approaches can reduce MR, suggesting there is a great deal of potential for clinical benefit to patients with MR.
Abstract: Percutaneous coronary intervention (PCI) to aorto-ostial (AO) lesions is technically demanding and associated with high revascularization rates. The aim of this study was to assess outcomes after bare metal stent (BMS) compared to drug-eluting stent (DES) implantation after PCI to AO lesions. A retrospective cohort analysis was conducted of all consecutive patients who underwent PCI to AO lesions at 2 centers. Angiographic and clinical outcomes in 230 patients with DES from September 2000 to December 2009 were compared to a historical control group of 116 patients with BMS. Comparison of the baseline demographics showed more diabetics (32% vs 16%, p = 0.001), lower ejection fractions (52.3 ± 9.7% vs 55.0 ± 11.5%, p = 0.022), longer stents (17.55 ± 7.76 vs 14.37 ± 5.60 mm, p <0.001), and smaller final stent minimum luminal diameters (3.43 ± 0.53 vs 3.66 ± 0.63 mm, p = 0.001) in the DES versus BMS group. Angiographic follow-up (DES 68%, BMS 66%) showed lower restenosis rates with DES (20% vs 47%, p <0.001). At clinical follow-up, target lesion revascularization rates were lowest with DES (12% vs 27%, p = 0.001). Cox regression analysis with propensity score adjustment for baseline differences suggested that DES were associated with a reduction in target lesion revascularization (hazard ratios 0.28, 95% confidence interval 0.15 to 0.52, p <0.001) and major adverse cardiac events (hazard ratio 0.50, 95% confidence interval 0.32 to 0.79, p = 0.003). There was a nonsignificantly higher incidence of Academic Research Consortium definite and probable stent thrombosis with DES (n = 9 [4%] vs n = 1 [1%], p = 0.131). In conclusion, despite differences in baseline characteristics favoring the BMS group, PCI with DES in AO lesions was associated with improved outcomes, with lower restenosis, revascularization, and major adverse cardiac event rates.
Abstract: To investigate the predictors of moderate-to-severe aortic regurgitation (AR≥2+) after CoreValve implantation and evaluate the feasibility and safety of postdilatation in reducing the degree of AR.
Abstract: The aim of this study was to evaluate long-term clinical outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO).
Abstract: The aim of this study was to evaluate the incidence, predictors, management, and clinical outcomes in patients with grade III coronary perforation during percutaneous coronary intervention.
Abstract: To assess outcomes after transcatheter aortic valve implantation (TAVI) according to sex, with the two available valves and four recognised delivery approaches.
Abstract: There is a paucity of data on long-term outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) in the high-risk group of patients with diabetes mellitus (DM). The aim of this study was to evaluate long-term clinical outcomes after PCI of CTOs in patients with and without DM. A total of 1,742 patients with known DM status underwent PCI of CTOs at 3 tertiary care centers in the United States, South Korea, and Italy from 1998 to 2007. Five-year clinical outcomes were evaluated in patients with successful versus failed CTO PCI and the use of drug-eluting stents (DES) versus bare-metal stents (BMS) stratified according to DM status. A total of 395 patients (23%) had DM (42% of whom had insulin-dependent DM). Procedural success was similar in patients with versus without DM (69.6% vs 67.9%, p = 0.53). After successful CTO PCI, stents were implanted in 96.4% of patients with DM (BMS in 23.8%, DES in 76.2%) and in 94.0% of patients without DM (BMS in 38.6%, DES in 61.4%). Median follow-up was 3.0 years. In patients with DM, successful CTO PCI was associated with reduced long-term mortality (10.4% vs 13.0%, p <0.05) and a reduced need for coronary artery bypass grafting (2.4% vs 15.7%, p <0.01). The use of DES was associated with a reduction in target vessel revascularization in patients with DM (14.8% vs 54.1%, p <0.01) and in those without DM (17.6% vs 26.5%, p <0.01). Multivariate analysis identified insulin-dependent DM as an independent predictor of mortality in the DM cohort. In conclusion, successful CTO PCI in patients with DM was associated with a reduction in mortality and the need for coronary artery bypass grafting. Compared to non-insulin-dependent DM, patients with insulin-dependent DM had an increased risk for long-term mortality. The use of DES rather than BMS was associated with a reduction in target vessel revascularization in patients with and without DM.
Abstract: Mitral regurgitation (MR) is a disabling disease associated with poor prognosis and high incidence of clinical events if left untreated. To reduce the invasiveness of the surgical approach, different types of transcatheter procedures are becoming available. The MitraClip procedure (Abbott Vascular Inc. Menlo Park, CA, USA) is yet the only catheter-based procedure available in clinical practice at the moment. The device has been evaluated in a number of preclinical studies, registries and in FDA approved clinical trials. (EVEREST trial, ACCESS-EU trial). Indication and timing of intervention is a crucial step in the diagnostic-therapeutic pathway of patients with mitral regurgitation. The aim of this review is to clarify the potential of MitraClip in clinical practice, particularly focusing on patient selection for this novel therapy. Patient selection and overall decision making is strongly influenced by anatomical and clinical factors. Decision-making in degenerative MR (DMR) vs. functional (FMR) can be quite different. Generally, MitraClip is effective in treating either type II or IIIb dysfunction (at the moment FMR is the main indication for MitraClip in Europe, according to the ACCESS registry data). The relative role of MitraClip and surgery in the management of patients with MR is still unclear. From the global initial experience, MitraClip therapy could be complementary to surgery in those patients at high risk for surgery who have ideal anatomical characteristics for implantation. The procedure is quite predictable in patients with favorable anatomy. In patients with suboptimal anatomy, if the risk of surgery is too high, MitraClip could be still indicated sometimes. Our preliminary experience suggests that in patients with DMR, the EVEREST anatomical criteria are strong predictors of early and mid-term success. According to it, MitraClip therapy is appropriate in those DMR patients with high surgical risk and ideal anatomy for clip implantation according to the EVEREST criteria. In FMR refractory to medical therapy and resynchronization therapy, MitraClip could be considered as first option therapy, particularly in those patients with comorbidities, or advanced age, being the operative risk of surgery above 5% in this population. In the future, novel devices, improved knowledge, more efficient imaging and transcatheter mitral prosthetic valve implantation may expand the indications to those patients currently not treated by MitraClip for anatomical unsuitability, and may improve the results both in term of early efficacy and long term durability.
Abstract: Stent thrombosis (ST) and restenosis are concerns after percutaneous coronary intervention (PCI). Limited information exists concerning clinical and angiographic outcomes following multiple stent insertion. We therefore present the long-term outcome from drug-eluting stent (DES) insertion and correlate this with the Syntax score.
Abstract: To describe results from a novel percutaneous technique designed to minimize the risk of hemorrhage in the event of a major complication during transcatheter aortic valve implantation.
Abstract: To evaluate clinical outcomes in patients undergoing carotid artery stenting (CAS) with routine use of a cerebral embolic protection device (EPD).
Abstract: The aim of the study was to assess whether trimetazidine (TMZ) could affect dispersion of atrial depolarization and ventricular repolarization. Corrected QT interval (QTc), QTc dispersion (QTc-d), Tpeak-Tend, and Tpeak-Tend dispersion (Tpeak-Tend-d) were measured in 30 patients with chronic heart failure (CHF) before and 6 months after randomization to conventional therapy plus TMZ (17 patients) or conventional therapy alone (13 patients). After 6 months, QTc was significantly reduced in both groups, whereas QT-peak was increased only in control group. Tpeak-Tend-d decreased (from 63.53 +/- 24.73 to 42.35 +/- 21.07 milliseconds, P = .006) only in TMZ group. When subgrouped according to CHF etiology, only ischemic patients on TMZ showed Tpeak-Tend-d reduction (65.00 +/- 27.14 vs 36.67 +/- 11.55 milliseconds, P = .001 in ischemic patients; 60.00 +/- 20.00 vs 56.00 +/- 33.86 milliseconds, P = NS, in nonischemic). These electrophysiological properties indicate an undiscovered mechanism of action of TMZ, which could be useful in conditions at risk of major arrhythmias.
Abstract: Limited data are available on the long-term outcome following PCI with paclitaxel-eluting stent (PES) implantation in patients with unprotected left main coronary artery (LMCA). The objective of this study was to evaluate "real world" long-term outcome following paclitaxel-eluting stent (PES) implantation for unprotected LMCA disease in patients enrolled in the TRUE registry.
Abstract: Diabetes mellitus (DM) accounts for >25% of all percutaneous coronary interventions. In patients with DM, drug-eluting stent implantation is associated with a reduced risk of restenosis and target lesion revascularization. However, concern has been raised about the incidence of late and very late stent thrombosis and the increased mortality rate, mostly after thienopyridine withdrawal. We evaluated the long-term prognostic effect of thienopyridine discontinuation after drug-eluting stent implantation on the subsequent occurrence of stent thrombosis and all-cause death among a cohort of high-risk "de novo" diabetic patients. From May 2002 to December 2005, 542 consecutive patients with DM underwent drug-eluting stent implantation at 2 hospitals in Milan, Italy. For study purposes, only the 217 patients who had not previously undergone percutaneous or surgical revascularization were considered in the final analysis. The follow-up time was curtailed at 3.5 years. Detailed information about dual antiplatelet therapy (DAT) were collected for all patients included. Of the 217 patients, 15 died (6.9%); in 9 cases, the cause of death was cardiac (4.1%). The incidence of cumulative stent thrombosis was 4.6% (10 patients); 3 stent thromboses were early (1.38%), 5 late (2.3%), and only 2 were very late (0.9%). Of the 10 cases of stent thrombosis, 5 were definite and 5 were probable. Most (80%) of the stent thromboses occurred within the first 6 months during DAT. The median duration of DAT was 420 days (interquartile range 350 to 859). DAT discontinuation was the only independent predictor of the follow-up events (hazard ratio 20.42, 95% confidence interval 4.99 to 83.62). In conclusion, DM remains an independent adverse factor on clinical outcome. In this setting, prolonged DAT, even beyond that recommended in the guidelines, might be beneficial.
Abstract: Investigation of the correlation between bifurcation angles and outcomes is limited with discordant results. The aim of this study is to investigate left main (LM) and non-left main (N-LM) bifurcation angles and their modification after percutaneous coronary intervention (PCI). Measurement of all three angles adds to our understanding of bifurcation anatomy and the resultant effect of different stenting techniques.
Abstract: Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains a major challenge in interventional cardiology. Successful recanalization of a CTO can alleviate angina, reduce the need for coronary artery bypass surgery and increase long-term survival. Improving results from the historically quoted success rates of 50% to the levels now routinely quoted by some operators (80-90%), requires not just skill and experience, but also a thorough understanding of the wide array of materials and techniques now available in this area. The decision to attempt PCI of a CTO (versus continued medical therapy or surgical revascularization) requires an individualized risk/benefit analysis, encompassing clinical, imaging and technical considerations.
Abstract: Aortic stenosis (AS) and mitral regurgitation (MR) account for the majority of valvular diseases and their prevalence is increasing according to increased life expectancy. Surgical treatment is the gold standard, although operative risk may be high in some patients due to comorbidities and age. A large part of the patients at high surgical risk who could beneficiate of treatment are not referred to surgery. Therefore, there is a need of alternative and less invasive procedures.
Abstract: Poor long-term outcomes after percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) of saphenous vein grafts (SVGs) have been reported. However, limited data are available evaluating the use of modern techniques in this group. The aim of the present study was to assess the efficacy and long-term outcomes of PCI in SVG CTO with the routine use of embolic protection devices and drug-eluting stents. A retrospective cohort analysis was conducted of all consecutive patients undergoing PCI to SVG CTO from May 2002 to July 2009 at 2 centers. The indication for PCI was the presence of angina or silent ischemia with evidence of inducible ischemia after functional testing in the territory supplied by the SVG, despite optimal medical therapy. We identified 34 patients with SVG CTO. Of the 34 patients, 23 (68%) underwent successful SVG recanalization with stent implantation. An embolic protection device was used in 78% and 95% of stents implanted were drug-eluting stents. No in-hospital major adverse cardiac events occurred in the successful PCI group; one myocardial infarction occurred in the unsuccessful group. At follow-up (median 18.0 months, interquartile range 10.4 to 48.3), 1 case of myocardial infarction had occurred in the successful group. The in-stent restenosis rate was 68% (n = 13), of which 77% were focal, with target vessel revascularization in 61%. In conclusion, despite the relatively low procedural success rates, the clinical outcomes after successful PCI to SVG CTO with modern techniques were favorable. The repeat revascularization rates were high; however, graft patency was achievable in most after reintervention.
Abstract: Our aim was to assess clinical outcome after transcatheter aortic valve implantation (TAVI) performed with the 2 commercially available valves with 3 delivery approaches selected in a stepwise fashion.
Abstract: Previous data showed that recanalization of chronic total occlusions (CTO) with the subintimal tracking and reentry (STAR) technique is feasible. However, this technique is challenging and requires skilled operators to be performed. The aim of this study was to evaluate procedural and clinical outcomes of patients undergoing a contrast-guided STAR procedure.
Abstract: We sought to evaluate at 5 years the occurrence of cardiac death; cardiac death, and/or myocardial infarction (MI); cardiac death, MI, and/or stroke; target vessel revascularization; and major adverse cardiac and cerebrovascular events following percutaneous coronary intervention (PCI) with drug-eluting stent (DES) versus coronary artery bypass graft (CABG) in unprotected left main coronary artery lesions.
Abstract: Dual anti-platelet therapy with aspirin and a thienopyridine (DAT) is used to prevent stent thrombosis after percutaneous coronary intervention (PCI). Low response to clopidogrel therapy (LR) occurs, but laboratory tests have a controversial role in the identification of this condition.
Abstract: The aim of this study was to evaluate the efficacy and safety of unrestricted everolimus-eluting stent (EES) implantation in a contemporary cohort of real-world patients.
Abstract: Little information is available on the outcome after rotational atherectomy (RA) followed by drug-eluting stent (DES) implantation in calcified coronary lesions. The aim of this study was to evaluate the outcome of patients with severe lesion calcification undergoing RA followed by implantation of DES.
Abstract: Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The appropriate use of the rapidly increasing range of tools available to interventional cardiologists is bringing more and more CTOs into the 'treatable' category. The bar has now been raised to 80% success rates by some expert operators around the world, which, in our view, cannot be achieved without a thorough understanding of technique and technical know-how. CTO procedures are increasingly becoming a sub-specialist field within interventional cardiology and we would encourage centers to consider appointing 'super-specialists' who are able to concentrate experience and expertise in this area. In this paper we detail the principal characteristics of the over the wire balloons, microcatheters and guidewires at present available, the most popular and recent of which are listed in Table 1 and 2. The knowledge and the specific choice of these materials and the criteria for selection of your guidewire or microcatheter can mean the difference between success and failure. Moreover, we discuss on the most important and groundbreaking techniques to approach a CTO. Finally, considering the greater risk of coronary perforation related to a CTO procedure compared to routine PCI, we describe which are best strategy and devices for treating coronary perforations and other major complications.
Abstract: Limited long-term data exist on patients who have undergone drug-eluting stenting of very long lesions (requiring >or=60 mm of continuous stent) in native coronary arteries ("full-metal jacket").
Abstract: To assess the procedural and clinical outcomes from a modified subintimal tracking and re-entry (STAR) procedure performed using contrast guidance.
Abstract: Prolonged periods of dual antiplatelet therapy (DAT), i.e., aspirin plus a thienopyridine, are currently recommended to prevent late drug-eluting stent (DES) thrombosis. The aim of our study was to determine the risk and predictors of bleeding and compliance associated with such prolongation of DAT. In this observational study we examined 2,355 consecutive patients undergoing successful DES implantation at 4 hospitals in Italy from June 2002 to December 2004. Bleeding events occurring on DAT and warfarin or in the first 30 days after stent implantation were excluded. Median duration of DAT was 209 days (interquartile range 178 to 444) and only 158 patients (6.7%) prematurely discontinued DAT. The overall bleeding rate was 1.9% (45), with major bleeding in 19 (0.8%) and minor bleeding in 26 (1.1%). Independent predictors of bleeding were DAT (hazard ratio 19.8, 95% confidence interval [CI] 3.69 to 106.34, p <0.001) and age >65 years (hazard ratio 2.15, 95% CI 1.16 to 4.00, p = 0.02). In patients on DAT, the incidence rate (30 days to 18 months) of any bleeding event was 2.57 per 100 person-years (95% CI 1.85 to 3.48) and major bleeding was 1.10 per 100 person-years (95% CI 0.65 to 1.74). In conclusion, DAT after DES implantation is well tolerated and associated with a very low risk of major bleeding.
Abstract: The purpose of this study was to evaluate the safety of dual antiplatelet therapy in patients in whom long-term anticoagulation (AC) with warfarin is recommended.
Abstract: The aim of the study was to compare the outcomes of sirolimus-eluting (SES) and paclitaxel-eluting (PES) stent implantation in coronary bifurcations treated with either a 1-stent or 2-stent strategy.
Abstract: Several randomized trials have shown that sirolimus-eluting stents and paclitaxel-eluting stents (PES) are effective in reducing restenosis in respect to bare-metal stents, including the subset of small vessels. The objective of this study was to evaluate "real world" angiographic and clinical outcomes of a large series of patients enrolled in the TRUE registry and treated with PES for both small vessel and very small vessel lesions. A consecutive series of 675 patients (926 lesions) with reference vessel diameter <2.75 mm measured by quantitative coronary angiography analysis were analyzed. The primary end point was the rate of angiographic in-stent restenosis and 1-year major adverse cardiac events. In this study 390 lesions were identified as small vessel (reference vessel diameter >or=2.25 and <2.75 mm) and 536 lesions as very small vessel (reference vessel diameter <2.25 mm). Overall in-stent restenosis was 15.5% (n = 96). Compared with small vessel, the very small vessel lesions had more in-stent restenosis (21.7% vs 11.4%, p <0.001) and in-segment restenosis (29.3% vs 22.5%, p = 0.055). The majority of the restenotic lesions (n = 125) were focal (57%, n = 71). At 1 year, cardiac death was 1.6% (n = 11), acute myocardial infarction 0.5% (n = 4.), and the target lesion revascularization 12.8% (n = 86). Cumulative major adverse cardiac events rate was 17.3% (n = 119). The rate of definite and probable stent thrombosis was 0.9% (n = 8). In conclusion, in comparison with historical bare-metal stent controls, this large series of small vessel lesions treated with PES confirms previous results reporting the efficacy of PES in small vessels. The rate of subacute and late stent thrombosis was low in this subgroup of patients.
Abstract: The T-cell receptor zeta (TCR zeta)-chain is a master sensor and regulator of lymphocyte responses. Loss of TCR zeta-chain expression has been documented during infectious and inflammatory diseases and defines a population of effector T cells (TCR zeta(dim) T cells) that migrate to inflamed tissues. We assessed the expression and functional correlates of circulating TCR zeta(dim) T cells in coronary artery disease.
Abstract: Nitroprusside (NTP) is used for the treatment of slow coronary flow (SCF) after coronary interventions. The wide variation in dosage, route, and timing of its administration in the reported studies prevents an objective assessment of its efficacy. We report the incidence and response to a standardized NTP protocol of SCF after successful stent implantation. Selective intracoronary administration of incremental doses (initial bolus of 80 microg incremented by 40 microg) of NPT was assessed in 21 patients who developed SCF in a series of 2,212 consecutive patients who underwent successful stent placement from January to October 2005. SCF was observed only in patients treated for acute myocardial infarction (AMI; 11.5%, 12 of 105) or saphenous vein graft (SVG) stenosis (8.2%, 9 of 109). An intracoronary bolus of nitroglycerin did not restore normal Thrombolysis In Myocardial Infarction (TIMI) flow in any patient. The first 80-microg dose of NTP restored normal TIMI flow in 58% of patients (7 of 12) with AMI and in 44% of patients (4 of 9)with SVG stenosis. The maximal dose (120/160 microg) restored normal TIMI flow in all remaining patients with AMI but in only 1 additional patient with SVG stenosis. At the end of the procedure, the percent decrease in corrected TIMI frame count was significantly larger in patients with AMI (-44+/-10%) than in those with SVG stenosis (-24+/-16%, p=0.02). In a large consecutive series of successful stent procedures, SCF was found only in patients with ST-elevation AMI (11.5%) or with a stenosed SVG (8.2%). In conclusion, the standardized protocol of intracoronary NTP administration succeeded in normalizing SCF in all patients with AMI but in only 5 of 9 patients with SVG stenosis. This latter subgroup requires other therapeutic strategies.
Abstract: The aim of the study was the assessment of the clinical, angiographic and procedural characteristics correlated with freedom from adverse events at 1 year in a real life setting of consecutive bifurcation lesions.
Abstract: The need for prolonged aspirin and thienopyridine therapy and the risk of stent thrombosis (ST) remain as drawbacks associated with drug-eluting stents.
Abstract: Percutaneous coronary intervention in a patient's last remaining coronary conduit is perceived to be high risk, although there are no published data on outcomes in this lesion cohort. We report our experience with 16 patients who underwent intervention in their sole remaining vessel between 1998 and 2005. All patients had previously undergone coronary artery bypass grafting, had a history of myocardial infarction, had impaired left ventricular systolic function, and were symptomatic with unstable angina or minimal effort angina. There was 1 periprocedural death 10 hours after the procedure, and another patient died 4 months after the procedure. At 6-month follow-up, 2 patients had undergone target lesion revascularization. There was a significant and sustained improvement in symptom status, with 75% of patients being asymptomatic or in Canadian Cardiovascular Society class I after 6 months. Given the complexity of the patients and lesions treated in this cohort, periprocedural and long-term outcomes are acceptable with a notable improvement in symptomatic status. In conclusion, these data support percutaneous intervention as a realistic treatment option for this often highly symptomatic and difficult-to-treat patient cohort.
Abstract: To evaluate patterns of restenosis following implantation of sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES) in comparable unselected lesions.
